Observations
Based on a review of personnel records and CPR certification cards, the facility failed to ensure that a sufficient number of staff persons, certified in CPR, where on site during the project's hours of operation.
The findings include:
Personnel records and employee CPR certification cards were reviewed on March 31, 2015 for the weeks of March 1-30, 2015. The facility is a 24 hour residential facility and requires 24 hour CPR coverage. The facility failed to document sufficient CPR coverage in four of the four weeks reviewed.
There were no staff with documented CPR certification on site from 3-4 PM on 3/3/15, 3/8/15, 3/9/15, 3/10/15, 3/15/15, 3/17/15, 3/22/15, 3/24/15 and 3/29/15.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
The program supervisor is responsible for insuring that all staff are current and up to date on the CPR/First Aid certification.
All Staff will complete CRP/First aid at new hire orientation unless a copy of a valid card is presented at hire. A copy of the card will be retained in the employee HR training file. HR will also provide a copy of the card to the onsite supervisor to retain with the annual training plan.
The onsite supervisor will monitor renewal needs of all staff in the program through the use of the yearly training plan and schedule recertification 60 days prior to expiration. A copy of the new renewal card will be retained by HR and a copy of the new card will be providing to the onsite supervisor to attach to the training plan. The Supervisor will document completion on the training plan.
All staff will be notified of this requirement by the program supervisor at the program staff meeting on 5/15/15 and place in the meeting minutes. At the present time all current employees at Gage House are current on both CPR and first aid.
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent from the client that included the specific information to be disclosed in nine of ten client records.
The findings include:
Ten client records were reviewed on March 31, 2015. Ten client records included consents signed by the client. Client records # 2, 3, 4, 5, 6, 7, 8, 9 and 10 included consents that did not document the specific information to be disclosed.
Client # 2 was admitted on January 2, 2015. Consents signed by the client on 1/2/15, 2/10/15, 2/13/15, 3/12/15, 3/27/15 did not document the specific information to be disclosed.
Client # 3 was admitted on February 16, 2015. Consents signed by the client on 2/13/15, 3/11/15, 3/25/15 and 3/28/15 did not document the specific information to be disclosed.
Client # 4 was admitted on March 12, 2015. Consents signed by the client on 3/10/15 and 3/22/15 did not document the specific information to be disclosed.
Client # 5 was admitted on November 24, 2014. Consents signed by the client on 11/21/14, 11/30/14, 1/18/15, 2/5/1 and 2/4/15 did not document the specific information to be disclosed.
Client # 6 was admitted on October 6, 2014. Consents signed by the client on 10/2/14, 10/14/14 and 11/1/14 did not document the specific information to be disclosed.
Client # 7 was admitted on August 22, 2014. Consents signed by the client on 8/24/14, 9/23/14 and 10/8/14 did not document the specific information to be disclosed.
Client # 8 was admitted on October 6, 2014. Consents signed by the client on 10/31/14, 11/1/14 and 11/18/14 did not document the specific information to be disclosed.
Client # 9 was admitted on December 23, 2014. Consents signed by the client on 12/23/14, 1/5/15, 1/15/15, 3/4/15, 3/6/15 and 3/12/15 did not document the specific information to be disclosed.
Client # 10 was admitted on November 15, 2014. Consents signed by the client on 12/10/14 and 12/22/14 did not document the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will review the completed ROI forms when completed to insure that staff are completing them correctly immediately. A monthly chart auditing form will be used ongoing to support continue compliance with this regulation. |